MEDICARE: TRUDY M MATTHYS RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	115401-1	MN

General Provider Information

NPI Number	:	1902188972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRUDY M MATTHYS RPH

Provider Business Mailing Address
First Line	:	7560 160TH STREET WEST
Second Line	:
City	:	LAKEVILLE
State	:	MN
Zip	:	55044
Country	:	US
Telephone Number	:	952-891-1167
Fax Number	:	952-891-3337

Provider Business Practice Location Address
First Line	:	7560 160TH STREET WEST
Second Line	:
City	:	LAKEVILLE
State	:	MN
Zip	:	55044
Country	:	US
Telephone Number	:	952-891-1167
Fax Number	:	952-891-3337

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2011
Last Update Date	:	09/15/2011

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